Getting healthcare via ACA

is like being grateful the mugger didn’t just kill you.

The appalling incompetence of the rollout of ACA might well stand as a symbol of the entire package. In America, the term ‘healthcare’ is an oxymoron, having very little to do with taking care of the health of the citizenry and much to do with making the insurance and pharmaceutical companies richer.
That’s the ONLY reason their lobbyists allowed the law to pass and they didn’t allow it until they were satisfied with the fine print. And, of course, until their political toadies’ speechwriters had come up with acceptable doublespeak.

It doesn’t have to be that way.

The biggest downside of the ACA is the reliance on the private insurance industry. [] There is yet another provision in the Affordable Care Act that can open the door for states to institute their own single-payer healthcare system.
Vermont decided to [] set[] up their very own single payer system.

The program will be fully operational by 2017, and will be funded through Medicare, Medicaid, federal money for the ACA given to Vermont, and a slight increase in taxes. In exchange, there will be no more premiums, deductibles, copay’s, hospital bills or anything else aimed at making insurance companies a profit. Further, all hospitals and healthcare providers will now be nonprofit.

Everybody in, nobody out.

Everyone will be able to go to any doctor or hospital in the state free of charge. No plans to figure out, no insurance forms to sweat over, no gotchas.

Another advantage of a single-payer system is the ability of the state [Vermont] to negotiate more aggressively with pharmaceutical companies and medical equipment suppliers There is no reason drugs and equipment should be so expensive here and cheaper abroad.

I haven’t seen the fine print on Vermont’s plan – don’t khow if it’s even gotten that far yet – so I can’t comment on the non-profit status of hospitals and healthcare providers, However, a good argument can be made that the first priority of a corporation should be to operate to the benefit of the public and only secondarily to the benefit of the corporate owners. That was, in fact, the original justification for corporations.
(Utah Phillips once spoke of the difference between making a living and making a killing.) 🙂

For millions of people, healthcare in this county sucks, particularly compared to other First World countries (which group is unlikely to include us a few years from now). I happen to have excellent medical coverage – unless I outlive my wife or the vultures manage to privatize USPS and loot the pension and benefit funds, in which case I’d be screwed. Vermont has been on my shortlist of possible places to relocate in the next year or two and a big part of that is their more humane sociopolitical outlook and culture. This just confirms that judgment.

4 Replies to “Getting healthcare via ACA”

  1. Here is a partial list of exclusions in an ACA compliant policy (Platinum level) from Humana:

    Limitations and exclusions (things that are not covered)
    This is an outline of the limitations and exclusions for the Humana individual health plan listed above. It is designed for convenient reference. Consult the policy for a
    complete list of limitations and exclusions.
    The policy is guaranteed renewable as long as premiums are paid. Other termination provisions apply as listed in the policy.
    Unless specifically stated otherwise, no benefits
    will be provided for, or on account of, the following
    1. Services which require a primary care physician
    referral if a referral was not obtained;
    2. Services provided by a non-network provider,
    except when:
    a. Authorized by us;
    b. A referral is obtained from a primary care
    physician; or
    c. The following services are medically
    necessary to render emergency care;
    i. Professional ambulance service;
    ii. Services in a hospital emergency room; or
    iii. Services in an urgent care center;
    3. Services provided by a non-network provider
    except as expressly provided in the policy;
    4. Services for care and treatment of non-covered
    5. Services incurred before the effective date or
    after the termination date;
    6. Services not medically necessary for diagnosis
    and treatment of a bodily injury or sickness,
    except for the specified routine preventive
    7. Charges for prophylactic services including, but
    not limited to, prophylactic mastectomy or any
    other services performed to prevent a disease
    process from becoming evident in the organ
    tissue at a later date;
    8. Services which are experimental,
    investigational or for research purposes, or
    related to such, whether incurred prior to, in
    connection with, or subsequent to the service
    which is experimental, investigational or
    for research purposes as determined by us.
    The fact that a service is the only available
    treatment for a condition may not make
    it eligible for coverage if we deem it to be
    experimental, investigational or for research
    9. Complications directly related to a service
    that is not a covered expense under the
    policy because it was determined by us to be
    experimental, investigational or for research
    purposes or not medically necessary. Directly
    related means that the service occurred
    as a direct result of the experimental,
    investigational or for research purposes or
    not medically necessary service and would
    not have taken place in the absence of the ,
    experimental, investigational or for research
    purposes or not medically necessary service;
    10. Charges in excess of the maximum allowable
    fee for the service;
    11. Services exceeding the amount of benefits
    available for a particular service;
    12. Services for any condition excluded by rider or
    amendment under the policy;
    13. Services provided when the policy is past
    premium due date, and payment is not
    14. Services for treatment of complications of noncovered
    procedures or services;
    15. Services relating to a sickness or bodily injury
    incurred as a result of the covered person:
    a. Being intoxicated, if the use of alcohol
    substantially contributes to or causes the
    loss, or if the covered person is intoxicated
    over the legal limit. A covered person is
    conclusively determined to be intoxicated
    over the legal limit if a chemical test
    administered in the jurisdiction where the
    loss occurred is at or above the legal limit
    set by that jurisdiction; or
    b. Being under the influence of illegal narcotics
    or controlled substance unless administered
    or prescribed by a healthcare practitioner;
    16. Services relating to a sickness or bodily injury
    as a result of:
    a. Intentionally self-inflicted bodily harm or
    attempted suicide whether sane or insane;
    b. War or an act of war, whether declared or
    c. Taking part in a riot as a voluntary
    d. Engaging in an illegal occupation as a
    voluntary participant; or
    e. Any act of armed conflict, or any conflict
    involving armed forces or any authority;
    17. Services:
    a. For charges which are not authorized,
    furnished or prescribed by a healthcare
    practitioner or healthcare treatment facility;
    b. For which no charge is made, or for
    which the covered person would not be
    required to pay if he/she did not have this
    insurance, unless charges are received
    from and reimbursable to the United States
    government, or any of its agencies as
    required by law;
    c. Furnished by or payable under any plan or
    law through a government or any political
    subdivision, unless prohibited by law;
    d. Furnished while a covered person is
    confined in a hospital or institution
    owned or operated by the United States
    government or any of its agencies for any
    service-connected sickness or bodily injury;
    e. For charges received from a healthcare
    practitioner over the rate we would pay for
    the least costly provider;
    f. Which are not rendered or not
    substantiated in the medical records;
    g. Provided by a family member or person who
    resides with the covered person;
    h. Rendered by a standby healthcare
    practitioner, surgical assistant, assistant
    surgeon, physician assistant, nurse or
    certified operating room technician unless
    medically necessary; or
    i. Performed in association with a non-covered
    18. Any charges, including healthcare practitioner
    charges, which are incurred if a covered
    person is admitted to a hospital on a Friday or
    Saturday unless:
    a. The hospital admission is due to emergency
    care; and
    b. Treatment or surgery is performed on that
    same day;
    19. Hospital inpatient services when the covered
    person is in observation status;
    20. Cosmetic services, or any complication
    21. Custodial care and maintenance care;
    22. Ambulance services for routine transportation
    to, from or between medical facilities and/or a
    healthcare practitioner’s office;
    23. Elective medical or surgical procedures except
    elective tubal ligation and vasectomy;
    24. Elective medical or surgical abortion unless:
    a. The pregnancy would endanger the life of
    the mother; or
    b. The pregnancy is a result of rape or incest;
    25. Reversal of sterilization;
    26. Infertility services except as expressly provided
    in the “Preventive services” provision in the
    “Your Policy Benefits” section;
    27. Sexual dysfunction;
    28. Sex change services, regardless of any
    diagnosis of gender role or psychosexual
    orientation problems;
    29. Vision examinations or testing for the
    purposes of prescribing corrective lenses;
    radial keratotomy; refractive keratoplasty;
    or any other surgery or procedure to correct
    myopia, hyperopia or stigmatic error; orthoptic
    treatment (eye exercises); or the purchase or
    fitting of eyeglasses or contact lenses, unless
    specified in the policy;
    30. Dental services, appliances or supplies for
    treatment of the teeth, gums, jaws or alveolar
    processes including, but not limited to,
    excision of partially or completely unerupted
    impacted teeth, any oral or periodontal surgery
    and preoperative and post operative care,
    implants and related procedures, orthodontic
    procedures, and any dental services related to
    a bodily injury or sickness except as expressly
    provided in the policy;
    31. Pre-surgical/procedural testing duplicated
    during a hospital confinement;
    32. Any treatment for obesity, regardless of any
    potential benefits for co-morbid conditions,
    including but not limited to:
    Network agreements
    Network providers agree to accept an agreed-upon amount as payment in full. Your policy explains your share of the cost of services rendered by network
    providers. It may include a deductible, a set amount (copayment), and a percent of the cost (coinsurance).
    When you go to a network provider:
    • The amount you pay is based on the agreed-upon amount.
    • The provider can’t “balance bill” you for charges greater than that amount.
    • There are primary care physician (PCP) selection requirements and specialist
    referral requirements.
    • Primary care physician (PCP) referral is not required for network obstetrician
    and gynecologist services.
    When you go to an out-of-network provider::
    • There is no coverage for out-of-network providers, except for emergency
    care as defined in your policy.
    Page 8 of 12
    a. Surgical procedures for morbid obesity;
    b. Services or procedures for the purpose of
    treating a sickness or bodily injury caused
    by, complicated by, or exacerbated by the
    obesity; or
    c. Complications related to any services
    rendered for weight reduction;
    33. Surgical procedures for the removal of excess
    skin and/or fat in conjunction with or resulting
    from weight loss or a weight loss surgery;
    34. Treatment of nicotine habit or addiction,
    including but not limited to, nicotine patches,
    hypnosis, smoking cessation classes, tapes
    or electronic media; except as eligible for
    coverage under preventive services;
    35. Educational or vocational training or therapy,
    services, and schools including but not limited
    to videos and books;
    36. Foot care services including but not limited to:
    a. Shock wave therapy of the feet;
    b. Treatment of weak, strained, flat, unstable
    or unbalanced feet;
    c. Hygienic care, and the treatment of
    superficial lesions of the feet, such as corns,
    calluses or hyperkeratosis;
    d. Tarsalgia, metatarsalgia or bunion
    treatment, except surgery which involves
    exposure of bones, tendons or ligaments;
    e. Cutting of toenails, except removal of nail
    matrix; and
    f. Arch supports, heel wedges, lifts, shoe
    inserts, the fitting or provision of foot
    orthotics or orthopedic shoes, unless
    medically necessary because of diabetes or
    37. Hair prosthesis, hair transplants or implants;
    38. Hearing care that is routine, including but
    not limited to exams and tests, any artificial
    hearing device, cochlear implant, auditory
    prostheses or other electrical, digital,
    mechanical or surgical means of enhancing,
    creating or restoring auditory comprehension;
    39. Services rendered in a premenstrual syndrome
    clinic or holistic medicine clinic;
    40. Transplant services except as expressly
    provided in the policy;
    41. Charges for growth hormones (drugs,
    medications or hormones to stimulate growth);
    42. Over the counter medical items or supplies
    that can be provided or prescribed by a
    healthcare practitioner but are also available
    without a written order or prescription, except
    for preventive services;
    43. Immunizations including those required for
    foreign travel for covered persons of any age
    except as expressly provided in the policy;
    44. Treatment for any jaw joint problem, including
    but not limited to, temporomandibular
    joint disorder, craniomaxillary disorder,
    craniomandibular disorder, head and neck
    neuromuscular disorder or other conditions of
    the joint linking the jaw bone and skull;
    45. Genetic testing, counseling or services;
    46. Charges for which there is automobile or any
    other insurance providing medical payments;
    47. Sickness or bodily injury for which medical
    payments/personal injury protection (PIP)
    coverage exists under any automobile,
    homeowner, marine, aviation, premise or any
    other similar coverage whether such coverage
    is in effect on a primary, secondary, or excess
    basis. This exclusion applies up to the available
    limit under the other coverage regardless
    of whether a claim is filed with the medical
    payments/PIP carrier. Whether medical
    payment or expense coverage is payable under
    another coverage is to be determined as if the
    coverage under the policy did not exist;
    48. Covered expense to the extent of any amount
    received from others for the bodily injuries
    or losses which necessitated such benefits.
    Amounts received from others specifically
    includes, without limitation, liability insurance,
    Workers’ Compensation, uninsured motorists,
    underinsured motorists, “no-fault” and
    automobile medical payments;
    49. Expense for employment, school, sports or
    camp physical examinations or for the purpose
    of obtaining insurance, premarital tests/
    50. Services received in an emergency room unless
    required because of emergency care;
    51. Any expense incurred for services received
    outside of the United States except as required
    by law for emergency care services;
    52. Services received during an inpatient
    stay when the stay is primarily related to
    behavioral, social maladjustment, lack of
    discipline or other antisocial actions which are
    not specifically the result of mental health;
    53. Services and supplies which are:
    a. Rendered in connection with mental
    illnesses not classified in the International
    Classification of Diseases of the U.S.
    Department of Health and Human Services;
    b. Extended beyond the period necessary
    for evaluation and diagnosis of learning
    and behavioral disabilities or for mental
    retardation; and
    c. Specifically excluded is marriage counseling;
    54. No benefits will be provided for:
    a. Immunotherapy for recurrent abortion;
    b. Chemonucleolysis;
    c. Biliary lithotripsy;
    d. Home uterine activity monitoring;
    e. Sleep therapy;
    f. Light treatment for Seasonal Affective
    Disorder (S.A.D.);
    g. Immunotherapy for food allergy;
    h. Prolotherapy;
    i. Cranial banding, unless otherwise
    determined by us;
    j. Hyperhydrosis surgery; and
    k. Sensory integration therapy;
    55. Services or supplies provided in connection
    with a sickness or bodily injury arising out of,
    or sustained in the course of, any occupation,
    employment or activity for compensation,
    profit or gain, whether or not benefits are
    available under Workers’ Compensation except
    as expressly provided in the policy;
    56. Court-ordered mental health services;
    57. Charges for alternative medicine, including
    medical diagnosis, treatment and therapy.
    Alternative medicine services includes, but is
    not limited to:
    a. Acupressure;
    b. Acupuncture;
    c. Aromatherapy;
    d. Ayurveda;
    e. Biofeedback;
    f. Faith healing;
    g. Guided mental imagery;
    h. Herbal medicine;
    i. Holistic medicine;
    j. Homeopathy;
    k. Hypnosis macrobiotic;
    l. Massage therapy;
    m. Naturopathy;
    n. Ozone therapy;
    o. Reflexotherapy;
    p. Relaxation response;
    q. Rolfing;
    r. Shiatsue; and
    s. Yoga;
    58. Services in a convenient care clinic;
    59. Private duty nursing;
    60. Living expenses; travel; transportation, except
    as expressly provided in the “Ambulance
    services” provision or “Transplants” provision in
    the “Your Policy Benefits” section of the policy;
    61. Charges for services that are primarily
    and customarily used for a non-medical
    purpose or used for environmental control or
    enhancement (whether or not prescribed by
    a healthcare practitioner) including but not
    limited to:
    a. Common household items such as air
    conditioners, air purifiers, water purifiers,
    vacuum cleaners, waterbeds, hypoallergenic
    mattresses or pillows, or exercise
    b. Scooters or motorized transportation
    equipment, escalators, elevators, ramps,
    modifications or additions to living/working
    quarters or transportation vehicles;
    c. Personal hygiene equipment including
    bath/shower chairs, transfer equipment or
    supplies or bed side commodes;
    d. Personal comfort items including cervical
    pillows, gravity lumbar reduction chairs,
    swimming pools, whirlpools or spas or
    e. Medical equipment including blood pressure
    monitoring devices, breast pumps, PUVA
    lights and stethoscopes;
    f. Charges for any membership fees or
    program fees paid by a covered person,
    including but not limited to, health
    clubs, health spas, aerobic and strength
    conditioning, work-hardening programs
    and weight loss or similar programs and
    any related material or products related to
    these programs;
    g. Communication system, telephone,
    television or computer systems and related
    equipment or similar items or equipment;
    h. Communication devices except after
    surgical removal of the larynx or a diagnosis
    of permanent lack of function of the larynx.
    Page 9 of 12
    Prescription Drug Exclusions
    1. Growth hormones (medications, drugs or
    hormones to stimulate growth) for idiopathic
    short stature;
    2. Growth hormones, (medications, drugs
    or hormones to stimulate growth), unless
    there is a laboratory confirmed diagnosis of
    growth hormone deficiency, or as otherwise
    determined by us;
    3. Contraceptives, including oral and transdermal,
    whether medication or device, when
    prescribed for purpose(s) other than to prevent
    4. Drugs which are not included on the drug list;
    5. Dietary supplements except enteral formulas
    and nutritional supplements for the treatment
    of phenylketonuria (PKU) or certain other
    inherited metabolic disease;
    6. Nutritional products;
    7. Fluoride supplements;
    8. Minerals;
    9. Herbs and vitamins;
    10. Legend drugs which are not deemed medically
    necessary by us;
    11. Any drug prescribed for a sickness or bodily
    injury not covered under the policy;
    12. Any drug prescribed for intended use other
    than for:
    a. Indications approved by the FDA;or
    b. Off-label indications recognized through
    peer-reviewed medical literature;
    13. Any drug, medicine or medication that is
    a. Labeled “Caution-limited by Federal law to
    investigational use”; or
    b. Experimental, investigational or for research
    purposes, even though a charge is made to
    the covered person;
    14. Allergen extracts;
    15. The administration of covered medication(s);
    16. Therapeutic devices or appliances, including
    but not limited to:
    a. Hypodermic needles and syringes except
    needles and syringes for use with insulin,
    and self-administered injectable drugs
    whose coverage is approved by us;
    b. Support garments;
    c. Test reagents;
    d. Mechanical pumps for delivery of
    medication; and
    e. Other non-medical substances;
    17. Anabolic steroids;
    18. Anorectic or any drug used for the purpose of
    weight control;
    19. Abortifacients (drugs used to induce abortions);
    20. Any drug used for cosmetic purposes, including
    but not limited to:
    a. Tretinoin, e.g. Retin A, except if the
    covered person is under the age of 45 or is
    diagnosed as having adult acne;
    b. Dermatologicals or hair growth stimulants;
    c. Pigmenting or de-pigmenting agents, e.g.
    21. Contrary to any other provisions of the policy,
    we may decline coverage or, if applicable,
    exclude from the drug list any and all
    prescriptions, including new indications for
    an existing prescription, until the conclusion
    of a review period not to exceed six months
    following FDA approval for the use and release
    of the prescription, including new indications
    for an existing prescription into the market;
    22. Any drug or medicine that is:
    a. Lawfully obtainable without a prescription
    (over the counter drugs), except insulin;
    or drugs, medicines or medications on
    the Women’s Healthcare Drug List with a
    prescription from a healthcare practitioner;
    b. Available in prescription strength without a
    23. Compounded drugs in any dosage form except
    when prescribed for pediatric use for children
    up to 19 years of age;
    24. Progesterone crystals or powder in any
    compounded dosage form, unless otherwise
    determined by us;
    25. Infertility services including medications;
    26. Any drug prescribed for impotence and/or
    sexual dysfunction, e.g. Viagra;
    27. Any drug, medicine or medication that is
    consumed or injected at the place where
    the prescription is given or dispensed by the
    healthcare practitioner;
    28. Drug delivery implants;
    29. Treatment for Onychomycosis (nail fungus);
    30. Prescriptions that are to be taken by or
    administered to the covered person, in whole
    or in part, while he/she is a patient in a facility
    where drugs are ordinarily provided by the
    facility on an inpatient basis. Inpatient facilities
    include, but are not limited to:
    a. Hospital;
    b. Skilled nursing facility; or
    c. Hospice facility;
    31. Injectable drugs, including but not limited to:
    a. Immunizing agents unless otherwise
    determined by us;
    b. Biological sera;
    c. Blood;
    d. Blood plasma;
    e. Self-administered injectable drugs or
    specialty drugs for which coverage is not
    approved by us; or
    f. Flu and pneumonia vaccines;
    32. Prescription refills:
    a. In excess of the number specified by the
    healthcare practitioner; or
    b. Dispensed more than one year from the
    date of the original order;
    33. Any portion of a prescription or refill that
    exceeds a 90-day supply when received from
    either a mail-order pharmacy or from a retail
    pharmacy that participates in our program
    which allows a covered person to receive a
    90-day supply of a prescription or refill;
    34. Any portion of a prescription or refill that
    exceeds a 30-day supply when received from
    a retail pharmacy that does not participate in
    our program which allows a covered person
    to receive a 90-day supply of a prescription or
    35. Any portion of a specialty drug or selfadministered
    injectable drug that exceeds a
    30-day supply, unless otherwise determined
    by us;
    36. Any drug for which preauthorization and
    notification or step therapy is required, and not
    37. Any drug for which a charge is customarily not
    38. Any portion of a prescription or refill that:
    a. Exceeds our drug specific dispensing limit
    (i.e. IMITREX);
    b. Is dispensed to a covered person whose
    age is outside the drug specific age limits
    defined by us;
    c. Is refilled early, as defined by us; or
    d. Exceeds the duration-specific dispensing
    39. Any drug, medicine or medication received by
    the covered person:
    a. Before becoming covered under the benefit;
    b. After the date the covered person’s
    coverage under the policy has ended;
    40. Any costs related to the mailing, sending or
    delivery of prescription drugs;
    41. Any intentional misuse of the benefit, including
    prescriptions purchased for consumption by
    someone other than the covered person;
    42. Any prescription or refill for drugs, medicines
    or medications that are lost, stolen, spilled,
    spoiled or damaged;
    43. Any drug, medication, or supply to eliminate
    or reduce a dependency on or addiction to
    tobacco and tobacco products except as
    eligible for coverage under preventive services;
    44. Any drug or biological that has received
    designation as an orphan drug unless
    approved by us;
    45. Any amount the covered person paid for a
    prescription that has been filled, regardless of
    whether the prescription is revoked or changed
    due to adverse reaction or change in dosage or
    prescription; and
    46. Prescription dru

    1. If this is Humana’s Platinum plan, the Bronze plan must be “Heart attack? Take two aspirin and call me in the morning”.

      It’s as though they ban 90% of the situations that would require payouts. And that’s without looking at the details of how much they pay for particular services or which circumstances are excluded by any riders or amendments – or judging the premiums.

      How can anybody look at that policy and not realize it’s a scam?

  2. I agree that even crappy coverage is better than none, but that fact itself speaks volumes about the way the country is run.

    The real benefit your friend will reap by being insured is that providers will no longer collect ‘full fare’.
    When I review my medical insurance payments, I see (just as an example), a billed amount of $250; Medicare ‘allowing’ $68 and paying $42; my secondary paying $26 and I pay nothing. Uninsured, I’d be on the hook for $250, not the $68 the provider ended up settling for.

    This tells me twe things:
    1) Providers have learned the game – to collect $68, bill $250.
    2) Providers stick it to the uninsured because they have nobody on their side.

    I don’t know if you read the good argument can be made link, but if corporations will not operate to the the benefit of the public, why are they entitled to the special financial and legal privileges corporations enjoy? Healthcare should be a not-for-profit universal entitlement, just like decent housing, employment, good schools and all the other civilized (i.e. socialist) goodies.

  3. steeleweed – I agree with much of what you have posted, except your opening comment. For millions of people, getting healthcare via ACA is the first medical insurance they have ever been able to afford. I have a friend, a diagnosed paranoid schizophrenic who works for a shitty, small manufacturing firm who doesn’t offer health insurance to their employees and he is now able to get coverage because of ACA. At 53 and unmarried, he has had a miserable existence, forgoing health care until he has problems so severe he has to go to an emergency room, like for an abcessed tooth. He was weeping on the phone the other night, telling me he is going to be able to get a “bronze” plan for about $285 per month. I agree we should have universal, single payer health insurance and I hope the CEOs of large insurance and pharmaceutical companies burn in Hell for the way they have raped American consumers – but please don’t belittle the good that the ACA has done for people like my friend and compare it to a “mugging”!

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